Endotracheal Intubation

ET Intubation- Definition, Anatomy of Respiratory Track, Types Of Tubes, Measurement of Tube, Measurement of mouth, Position, procedure, Tray Preparation, Education of Pts, Fixations, Testing of tube, Advantages, Disadvantages.

1. ENDOTRACHEAL INTUBATION VIKRAM SINGH RAJAWAT M.Sc (N), MBA Dy. NURSING SUPERINTENDENT JNU HOSPITAL

2. Indication for endotracheal intubation 1) For supporting ventilation in patient with some pathologic disease : U pper airway obstruction : R espiratory failure : L oss of conciousness

3. Indication for endotracheal intubation (con’t) 2) For supporting ventilation during general anesthesia Type of surgery : Operative site near the airway : Abdominal or thoracic surgery

4. Indication for endotracheal intubation (con’t) : Prone or lateral position : Long period of surgery Patient has risk of pulmonary aspiration Difficult mask ventilation

5. ANATOMY OF AIRWAY

6. AIRWAY ASSESSMENT S : Congenital anomalies ---> Pierre Robin syndrome , Down’s syndrome : Infection in airway--> Retropharyngeal abscess, Epiglottitis : Tumor in oral cavity or larynx 1) Condition that associated with difficult intubation

7. AIRWAY ASSESSMENT : Enlarge thyroid gland trachea shift to lateral or compressed tracheal lumen 1) Condition that associated with difficult intubation (con’t)

8. AIRWAY ASSESSMENT : Maxillofacial ,cervical or laryngeal trauma : Temperomandibular joint dysfunction : Burn scar at face and neck : Morbidly obese or pregnancy 1) Condition that associated with difficult intubation (con’t)

9. AIRWAY ASSESSMENT 2) Interincisor gap : normal -> more than 3 cms

10. AIRWAY ASSESSMENT 3) Mallampati classification: Class 3,4 -> may be difficult intubation Soft palate Uvula

11. AIRWAY ASSESSMENT grade 3,4 -> risk for difficult intubation Laryngoscopic view

12. AIRWAY ASSESSMENT 4) Thyromental distance : more than 6 cms

13. AIRWAY ASSESSMENT 5) Flexion and extension of neck

14. AIRWAY ASSESSMENT 6) Movement of temperomandibular joint (TMJ) Grinding

15. Equipment preparation

16. 1) Laryngoscope : handle and blade

17. LARYNGOSCOPIC BLADE Macintosh (curved) and Miller (straight) blade Adult : Macintosh blade, small children : Miller blade Miller blade Macintosh blade

18. 2) Endotracheal tube

19. Endotracheal tube Male: ID 8.0 mms . Female : ID 7.5 mms New born - 3 months : ID 3.0 mms 3-9 months : ID 3.5 mms 9-18 months : ID 4.0 mms 2- 6 yrs : ID = ( Age/3 ) + 3.5 > 6 yrs : ID = ( Age/4 ) + 4.5 1) Size of endotracheal tube : internal diameter (ID)

20. 3) Endotracheal tube cuff High volume Low pressure cuff Low volume High pressure cuff 2) Material : Red rubber or PVC

21. 4) Bevel 5) Murphy’s eye

22. 6) Depth of endotracheal tube : Midtrachea or below vocal cord ~ 2 cms Adult -> Male = 23 cms ,Female = 21 cms Children Oral endotracheal tube = ( Age/2 ) + 12 (cm) Nasal endotracheal tube = ( Age/2 ) + 15 (cm)

23. 7) Tube markings Z-79 Disposible (Do not reuse) Oral/ Nasal Radiopaque marker

24. 3) Other equipments 3.1 Stylet

25. 3.2 Oropharyngeal or nasopharyngeal airway Oral airway Nasal airway

26. 3.3) Suction catheter 3.4) Slip joint

27. 3.5) Face mask and self inflating bag 3.6) Magill forcep

28. 3.7) Syringe 3.8) Lubricating jelly 3.9) Plaster for strap endotracheal tube 4. Monitoring success of endotracheal intubation 4.1) Stethoscope 4.2) Endtidal - CO 2 4.3) Pulse oximeter

29. Sniffing position Flexion at lower cervical spine Extension at atlanto-occipital joint

30. Sniffing position

31. Steps of oroendotracheal intubation

32. Steps of oroendotracheal intubation Vareculla

33. Nasoendotracheal intubation

34. Nasoendotracheal intubation Advantage 1) Comfortable for prolong intubation in postoperative period 2) Suitable for oral surgery : tonsillectomy , mandible surgery 3) For blind nasal intubation 4) Can take oral feeding 5) Resist for kinking and difficult to accidental extubation

35. Disadvantage 1) Trauma to nasal mucosa 2) Risk for sinusitis in prolong intubation 3) Risk for bacteremia 4) Smaller diameter than oral route -> difficult for suction

36. Contraindication for nasoendotracheal intubation 1) Fracture base of skull 2) Coagulopathy 3) Nasal cavity obstruction 4) Retropharyngeal abscess

37. Complication of endotracheal intubation 1) During intubation : Trauma to lip, tongue or teeth : Hypertension and tachycardia or arrhythmia : Pulmonary aspiration : Laryngospasm : Bronchospasm

38. Complication of endotracheal intubation (Con’t) 1) During intubation : Laryngeal edema : A rytenoid dislocation -> hoarseness : Increased intracranial pressure : Spinal cord trauma in cervical spine injury : Esophageal intubation

39. Complication of endotracheal intubation(Con’t) : Obstruction from klinking , secretion or overinflation of cuff : Accidental extubation or endobronchial intubation : Disconnection from breathing circuit 2) During remained intubation

40. Complication of endotracheal intubation(Con’t) 2) During remained intubation : Pulmonary aspiration : Lib or nasal ulcer in case with prolong period of intubation : Sinusitis or otitis in case with prolong nasoendotracheal intubation

41. 3) During extubation Laryngospasm Pulmonary aspiration Edema of upper airway Complication of endotracheal intubation(Con’t)

42. Complication of endotracheal intubation(Con’t) 4) After extubation Sore throat Hoarseness Tracheal stenosis (Prolong intubation) Laryngeal granuloma